Provider Demographics
NPI:1619921715
Name:BERNARD, MARIE (NP)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:BERNARD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890-2025
Mailing Address - Country:US
Mailing Address - Phone:781-721-6262
Mailing Address - Fax:
Practice Address - Street 1:1353 DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-2932
Practice Address - Country:US
Practice Address - Phone:617-288-3230
Practice Address - Fax:617-288-4377
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA181681363LS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LS0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMB0610039IOtherSTATE CONTROLLED LICENSE
MA181681OtherRN/NP LICENSE
MAMB1321479OtherFEDERAL DEA REGISTRATION